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			<h3>Health / Fitness Pre-Participation Questionnaire:</h3>
			<p style="color:gray; font-size: 12px;">AHA/ACSM Health/Fitness Facility Pre Participation Screening Questionnaire</p><br/>
			<ul id="yes-no">
				<li>
                    <span style="margin-left: 14px; margin-left: -6px;">You have had:</span><br/>					
					<span style="color:gray; font-size: 12px;">If you marked any of the statements in this section, consult your physician or other appropriate healthcare provider before engaging in exercise. You may need to use a facility with a medically qualified staff.</span><br/>
					<span style="font-weight: bold; margin-left: -6px;">History:</span><br />
					<input type="checkbox" name="chkBxHistory1" value="heartAttack"/>A heart attack<br/>
					<input type="checkbox" name="chkBxHistory2" value="heartSurgery"/>Heart surgery<br/>
					<input type="checkbox" name="chkBxHistory3" value="cardiac"/>Cardiac catheterization<br/>
					<input type="checkbox" name="chkBxHistory4" value="coronary"/>Coronary angioplasty (PTCA)<br/>
					<input type="checkbox" name="chkBxHistory5" value="pacemaker"/>Pacemaker/implantable cardiac defibrillator/rhythm disturbance<br/>
					<input type="checkbox" name="chkBxHistory6" value="heartValve"/>Heart valve disease<br/>
					<input type="checkbox" name="chkBxHistory7" value="heartFailure"/>Heart failure<br/>
					<input type="checkbox" name="chkBxHistory8" value="heartTransplant"/>Heart transplantation<br/>
					<input type="checkbox" name="chkBxHistory9" value="congenital"/>Congenital heart disease<br/>
				</li>
				<li>
					<span style="font-weight: bold; margin-left: -6px;">Symptoms:</span><br />
					<input type="checkbox" name="chkBxSymptoms1" value="chestDiscomfort"/>You experience chest discomfort with exertion.<br/>
					<input type="checkbox" name="chkBxSymptoms2" value="breathlessness"/>You experience unreasonable breathlessness.<br/>
					<input type="checkbox" name="chkBxSymptoms3" value="dizziness"/>You experience dizziness, fainting, blackouts.<br/>
					<input type="checkbox" name="chkBxSymptoms4" value="medications"/>You take heart medications.<br/>
				</li>
				<li>
					<span style="font-weight: bold; margin-left: -6px;">Other health issues:</span><br />
					<input type="checkbox" name="chkBxSymptoms1" value="chestDiscomfort"/>You have diabetes.<br/>
					<input type="checkbox" name="chkBxSymptoms2" value="breathlessness"/>You have or asthma other lung disease.<br/>
					<input type="checkbox" name="chkBxSymptoms3" value="dizziness"/>You have burning or cramping in your lower legs when walking short distances.<br/>
					<input type="checkbox" name="chkBxSymptoms4" value="medications"/>You have musculoskeletal problems that limit your physical activity.<br/>
					<input type="checkbox" name="chkBxSymptoms1" value="chestDiscomfort"/>You have concerns about the safety of exercise.<br/>
					<input type="checkbox" name="chkBxSymptoms2" value="breathlessness"/>You take prescription medication(s).<br/>
					<input type="checkbox" name="chkBxSymptoms2" value="breathlessness"/>You are pregnant.<br/>
					<div class="rule"></div>
					
				</li>				
				<li>
				<span style="color:gray; font-size: 12px;">If you marked two or more of the statements in this section, you should consult your physician or other appropriate healthcare provider before engaging in exercise. You might benefit by using a facility with a professionally qualified exercise staff to guide your exercise program.</span><br/>
					<span style="font-weight: bold; margin-left: -6px;">Cardiovascular risk factors:</span><br />
					<input type="checkbox" name="chkBxSymptoms1" value="chestDiscomfort"/>You are a man older than 45 years.<br/>
					<input type="checkbox" name="chkBxSymptoms2" value="breathlessness"/>You are a woman older than 55 years, you have had a hysterctomy, or you are postmenopausal.<br/>
					<input type="checkbox" name="chkBxSymptoms3" value="dizziness"/>You smoke, or quite within the previous 5 month.<br/>
					<input type="checkbox" name="chkBxSymptoms4" value="medications"/>Your BP is greater than 140/90.<br/>
					<input type="checkbox" name="chkBxSymptoms1" value="chestDiscomfort"/>You don't know your BP.<br/>
					<input type="checkbox" name="chkBxSymptoms2" value="breathlessness"/>Your blood cholesterol level is &rsaquo;200 mg/dl.<br/>
					<input type="checkbox" name="chkBxSymptoms2" value="breathlessness"/>You don't know your cholesterol level.<br/>
					<input type="checkbox" name="chkBxSymptoms1" value="chestDiscomfort"/>You have a close blood relative who had a heart attack before age 55(father or brother)<br/><span style="padding-left: 48px;">or age 65 (mother or sister).</span> <br/>
					<input type="checkbox" name="chkBxSymptoms2" value="breathlessness"/>Your are physically inactive (i.e. you get less than 30 min. of physical activity on at least 3 days per week).<br/>
					<input type="checkbox" name="chkBxSymptoms2" value="breathlessness"/>You are more than 20 pounds overweight.<br/>
					<div class="rule"></div>
					<input type="checkbox" name="chkBxSymptoms2" value="breathlessness"/>None of the above is true.<br/>										
					<span style="color:gray; font-size: 12px;">You should be able to exercise safely without consulting your physician or other healthcare provider in a selfguided program or almost any facility that meets your exercise program needs</span>
				</li>
			</ul><br/>
			<p style="font-size: 11px; color: gray;">				
				Balady et al. (1998). AHA/ACSM Joint Statement: Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness 
				Facilities. Medicine <br/> &amp; Science in Sports &amp; Exercise, 30(6).  (Also in: ACSM’s Guidelines for Exercise Testing and Prescription, 7
				th Edition, 2005. Lippincott Williams and Wilkins <a href="http://www.lww.com" target="_blank">http://www.lww.com</a>)<br/>				
				<a href="www.acsm-msse.org/pt/pt-core/template-journal/msse/media/0698c.htm" target="_blank">www.acsm-msse.org/pt/pt-core/template-journal/msse/media/0698c.htm</a>
			</p><br/><br/>
			
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